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September 2016

Improving Communication About Serious Illness in Primary Care: A Review

Author Affiliations
  • 1Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
  • 2Division of Palliative Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
  • 3Ariadne Labs, Brigham and Women’s Hospital, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
  • 4Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
  • 5Department of Psychiatry, Brigham and Women’s Hospital, Boston, Massachusetts
  • 6Division of Palliative Care, Department of Medicine, Massachusetts General Hospital, Boston
  • 7Department of Care Coordination, Brigham and Women’s Hospital, Boston, Massachusetts
  • 8Department of Medical Management, Brigham and Women’s Physicians Organization, Boston, Massachusetts
  • 9Division of Aging, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
JAMA Intern Med. 2016;176(9):1380-1387. doi:10.1001/jamainternmed.2016.3212

Importance  The Institute of Medicine recently called for systematic improvements in clinician-led conversations about goals, values, and care preferences for patients with serious and life-threatening illnesses. Studies suggest that these conversations are associated with improved outcomes for patients and their families, enhanced clinician satisfaction, and lower health care costs; however, the role of primary care clinicians in driving conversations about goals and priorities in serious illness is not well defined.

Objective  To present a review of a structured search of the evidence base about communication in serious illness in primary care.

Evidence Review  MEDLINE was searched, via PubMed, on January 19, 2016, finding 911 articles; 126 articles were reviewed and selected titles were added from bibliography searches.

Findings  Review of the literature informed 2 major topic areas: the role of primary care in communication about serious illness and clinician barriers and system failures that interfere with effective communication. Literature regarding the role that primary care plays in communication focused primarily on the ambiguity about whether primary care clinicians or specialists are responsible for initiating conversations, the benefits of primary care clinicians and specialists conducting conversations, and the quantity and quality of discussions. Timely and effective communication about serious illness in primary care is hampered by key clinician barriers, which include deficits in knowledge, skills, and attitudes; discomfort with prognostication; and lack of clarity about the appropriate timing and initiation of conversations. Finally, system failures in coordination, documentation, feedback, and quality improvement contribute to lack of conversations.

Conclusions and Relevance  Clinician and system barriers will challenge primary care clinicians and institutions to meet the needs of patients with serious illness. Ensuring that conversations about goals and values occur at the appropriate time for seriously ill patients will require improved training, validation, and dissemination of patient selection tools, systems for conducting and revisiting conversations, accessible documentation, and incentives for measurement, feedback, and continuous improvement.

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